Hiding in Plain Sight Dealing with Undiagnosed Hypertension in the Community Health Center Jim Schultz MDMBA FAAFP DiMM Chief Medical Officer Neighborhood Healthcare April 11 2016 Sacramento University of Best Practices ID: 688455
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Banner Peak, Eastern SierrasSlide2
Hiding in Plain Sight:
Dealing with Undiagnosed Hypertension in the Community Health Center
Jim Schultz, MD,MBA, FAAFP, DiMM
Chief Medical OfficerNeighborhood HealthcareApril 11, 2016Sacramento University of Best PracticesSlide3
Hiding in Plain Sight (HIPS)Slide4
Hiding in Plain Sight (HIPS)
Nov 19, 2014 Vol 312, Number 19Slide5
Hiding in Plain Sight (HIPS)
Hypertension:
29
% prevalence among US adults (2011-2012)33% among adults 40-5965% among adults 60+42% among non-Hispanic blacksUp to 40% of HTN patients are NOT diagnosed~
67-71M
adults have hypertension
Nwankwo
T, Yoon SS, Burt V,
Gu
Q. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011–2012. NCHS data brief, no 133. Hyattsville, MD: National Center for Health Statistics. 2013.
Valderrama
AL, Gillespie C, King SC, George MG, Hong Y, Gregg E. Vital signs: awareness and treatment of uncontrolled hypertension among adults — United States, 2003–2010.
MMWR
. 2012;61:703-709.
Slide courtesy of CDCSlide6
Hiding in Plain Sight
1.Franco
OH,
PeetersA
,
BonneuxL
, de
LaetC
. Blood pressure in adulthood and life expectancy with cardiovascular disease in men and women: Life course analysis. Hypertension. 2005;46:280.2.Law M, Wald N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health TechnolAssess.
2003;7(31):
1-94
3.ChobanianAV
,
BakrisGL
, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Hypertension
2003;42:1206-52
.
Impact of
Hypertension:
Normal BP:
Life
5 years longerReduction in BP by 5mmHg: stroke risk by 34% ischemic heart dz by 21%Antihypertensive Rx associated with: 35-40% stroke risk 20-25% heart attack risk >50% CHF Slide7
Hiding in Plain Sight (HIPS)
Slide courtesy of CDCSlide8
Hiding in Plain Sight (HIPS)
Why undiagnosed?
No insurance
?
81.8
% have health insurance
No PCP?
82.5
% report having a usual source of care Don’t go to the MD? 61.7% have received care two or more times in the past year
Wall HK,
Hannan
JA, Wright JS. Patients with Undiagnosed Hypertension: Hiding in Plain Sight. JAMA. 2014;312(19):1973-74
.Slide9
HIPS JAMA conclusion:
Recommendations:
Assess practice data
Develop systematic approach to identify potentially undiagnosed hypertensivesEstimate HTN prevalence, use to track
‘The nation can and must improve hypertension control to reduce preventable myocardial infarctions and
stroke…improvement
can only occur if all patients with hypertension are promptly identified, accurately diagnosed, and provided with evidence-based treatment and support.’Slide10
Hiding in Plain Sight (HIPS)
Math!
‘BP Control rates’:
Typical calculation methodology:
denominator: ‘search for ICD code 401.x or I10’
numerator: ‘last SBP < 140 AND last DBP <90’
NQF Measure 18 Data DefinitionSlide11
Hiding in Plain Sight (HIPS)
Math! Example
1000 patient with dx of 401.x or I10
750 meet numerator criteria (<140 and < 90)
75%-
pretty good!
What if you have 500 undiagnosed patients?
Denominator changes to 1500
Control rate changes to 750/(1000+500)= 750/1500= 50%Slide12
Hiding in Plain Site at Geisinger
Used data from 400K+ adult outpatients to ID patients with HTN
The problem list
ICD-9 diagnosis Antihypertensive medications RxTwo elevated BP values based on JNC-7 criteria2 systolic measures ≥140 or 2 diastolic measures ≥90
Found 106K patients with one or more criteria
30%
based solely on #4 (i.e. undiagnosed)
HTN Prevalence –
~18.6% vs ~26.5%
Shah NR.
Identifying hypertension in electronic health records: a comparison of various approaches.
Paper presented at: AHRQ Comparative Effectiveness Research Methods Symposium; June 2009; Rockville, MD. Of Various Approaches. AHRQ Comparative Effectiveness Research Methods Symposium, Rockville, MD, June 2009.Slide13
Hiding in Plain Sight -
Palo Alto Medical Foundation
250,000 adult patients
2006 - 2008For patients with ≥ 2 BP readings of 140/90 or higher, an antihypertensive medication prescription, or both, 37.1
% did not have an ICD-9-CM code
HTN prevalence went from
18.0
%
to 28.7% Much more likely to be on an antihypertensive with a HTN diagnosis 92.6% diagnosed vs 15.8% undiagnosed, P < .001
Banerjee D, Chung S, Wong EC, Wang EJ, Stafford RS, Palaniappan LP. Underdiagnosis of hypertension using electronic health records.
Am J Hypertens
. 2012;25(1):97-102.Slide14
HIPS and the USPSTF 2015
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/high-blood-pressure-in-adults-screeningSlide15
HIPS and the USPSTF 2015
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/high-blood-pressure-in-adults-screening
ABPM: automated regular BPs taken at home
HBPM: home BP monitor by pt
‘…convincing evidence that ABPM
i
s the best method for diagnosing hypertension’
‘…significant discordance between the office diagnosis…and 12- and 24-hours average blood pressure using ABPM…’
‘…the USPSTF recommends ABPM as the reference standard for confirming the diagnosis of hypertension.’
‘…confirmation with HBPM may be acceptable.’
Annals of Internal Medicine • Vol. 163 No. 10 • 17 November 2015Slide16
Hiding in Plain Sight (HIPS)Local and project baseline data- HTN control
7443 / 9748, 76%Slide17
Hiding in Plain Sight (HIPS)
Local and project baseline data- DM HTN control
4453 / 5541
80%Slide18
Hiding in Plain Sight (HIPS)
Mean= 6.9%Slide19
Hiding in Plain Sight (HIPS)Slide20
Hiding in Plain Sight (HIPS)- NHC Results
Overall Prevalence:
27.5%Slide21
Hiding in Plain Sight (HIPS)- NHC Results Slide22
Hiding in Plain Sight (HIPS)- NHC Results Slide23
(HIPS)- NHC
Results- Why so low?
Population HealthSlide24
(HIPS)- NHC Results- Why so low?Slide25
(HIPS)- NHC Results- Why so low?
Huddles
Right information
To the right people
At the right time
In the right formatSlide26
(HIPS)- NHC
Results- Why so low?
People
Erica Bazan, MA
Maria Acosta, MA
Erika Cruz, MASlide27
Hiding in Plain Sight (HIPS)- NHC Results Slide28
Hiding in Plain Sight (HIPS)- NHC Results Slide29
Neighborhood Healthcare HIPS
Interventions
Workflow in-office:
BP measurement training/standardization
Huddle- include ‘check last BP”
Recheck BP if elevated
Configure alerts app to alert for last BP
Configure alerts app for 2 BPs/no dx
Pop Health approaches (out-of-office):
RN or Care Coordinator visit for elevated BP/no dx
Registry recall lists for elevated BP/no dx
Incorporate HIPS into MTM (
PharmD
) visits
Phone follow up visits
Clinical:
HTN Treatment Protocol
Motivational interviewing/health coaching
Use of home BPs (ambulatory automatic BPs pending)
Use of integrated BH
Scorecards (
unblinded
, individual and by site)Slide30
HTN Treatment ProtocolSlide31
HTN Treatment ProtocolSlide32
Hiding in Plain Sight (HIPS)- NHC Results Slide33
Hiding in Plain Sight (HIPS)
CDC HTN Prevalence estimator tool
http://12.29.70.98/MillionHearts/Estimator
/Slide34
Hiding in Plain Sight (HIPS)CDC HTN Prevalence estimator toolSlide35
Hiding in Plain Sight (HIPS)Slide36
Hiding in Plain Sight (HIPS)Slide37
La Maestra: What’s working
The i2i huddle
sheet. Slide38
La Maestra: What’s working
i2i reports
run quarterly: Slide39
Hiding in Plain Sight (HIPS)Resources:
http://
millionhearts.hhs.gov/Docs/HTN_Change_Package.PDF
HTN control an organizational priority
A process to address BP at every visit
Accurate BP measurement
Evidence-based HTN treatment guidelines
Staff equipped to facilitate self-management
Proactive office encounters/huddles
Registry to identify and track
C
linician-managed Rx escalation protocols
PDSA- use own data to drive improvement
Make it easy to do the right and best thingSlide40
Hiding in Plain Sight (HIPS)
Other issues;
Pts not coming in to the office
50% hospital discharge no show rate
ER-
philes
HEDIS vs. USPSTF and ABPM
‘
Unreimbursable’ activitiesno global risk payoffPopulation HealthCare Coordinator visitsPhone follow upsEMR issuesCustom alerts limitations
Pop health/registries limited
NQF/HEDIS vs. JNC 8Slide41
Kalalau
Beach, Kauai
October 2014